Performance of the PEdiatric Logistic Organ Dysfunction-2 score in critically ill children requiring plasma transfusions.

BACKGROUND: Organ dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions. METHODS: This was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer-Lemeshow test). RESULTS: Four hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71-0.81) and the Hosmer-Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1. CONCLUSIONS: In a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.

Indications and Effects of Plasma Transfusions in Critically Ill Children.

RATIONALE: Plasma transfusions are frequently prescribed for critically ill children, although their indications lack a strong evidence base. Plasma transfusions are largely driven by physician conceptions of need, and these are poorly documented in pediatric intensive care patients. OBJECTIVES: To identify patient characteristics and to characterize indications leading to plasma transfusions in critically ill children, and to assess the effect of plasma transfusions on coagulation tests. METHODS: Point-prevalence study in 101 pediatric intensive care units in 21 countries, on 6 predefined weeks. All critically ill children admitted to a participating unit were included if they received at least one plasma transfusion. MEASUREMENTS AND MAIN RESULTS: During the 6 study weeks, 13,192 children were eligible. Among these, 443 (3.4%) received at least one plasma transfusion and were included. The primary indications for plasma transfusion were critical bleeding in 22.3%, minor bleeding in 21.2%, planned surgery or procedure in 11.7%, and high risk of postoperative bleeding in 10.6%. No bleeding or planned procedures were reported in 34.1%. Before plasma transfusion, the median international normalized ratio (INR) and activated partial thromboplastin time (aPTT) values were 1.5 and 48, respectively. After plasma transfusion, the median INR and aPTT changes were -0.2 and -5, respectively. Plasma transfusion significantly improved INR only in patients with a baseline INR greater than 2.5. CONCLUSIONS: One-third of transfused patients were not bleeding and had no planned procedure. In addition, in most patients, coagulation tests are not sensitive to increases in coagulation factors resulting from plasma transfusion. Studies assessing appropriate plasma transfusion strategies are urgently needed.

Journey from pediatric intensive care to palliative care.

BACKGROUND: Approximately two-thirds of patients who die in the pediatric intensive care unit (PICU) do so following withdrawal of intensive care treatment. Most often when intensive care treatment is withdrawn, the child remains in the PICU for end-of-life care. OBJECTIVES: This study aimed to examine the process of referral over a 6-year period of children from a PICU to children's hospices for end-of-life care. METHODS: This study carried out a retrospective review of all children referred from a large tertiary-level United Kingdom PICU to children's hospices over a 6-year period. Information was collected both from the PICU and from the hospices involved. RESULTS: A total of 12 children were transferred over the 6-year period. Discussions about limitation of treatment occurred after an average of 9 days of ventilation, with time from initial referral to transfer taking an additional 4 days such that the mean stay on the PICU prior to transfer was 13 days. Two-thirds of families had prior contact with the palliative care team involved. One-third of the patients were transported to the hospice while still dependent on mechanical invasive ventilatory support. All children were extubated by a PICU consultant within 90 minutes of arrival at the hospice. Overall, eight children died soon after transfer, with four children surviving beyond 2 weeks after transfer. CONCLUSION: This study suggests that there is a feasible alternative location for withdrawal of intensive care and/or compassionate extubation. The study found that one-third of children transferred to hospice for end-of-life care survived the initial withdrawal of intensive therapy; hence, parallel planning should be discussed prior to transfer to hospice. Information gained from this study has contributed toward the creation of a national care pathway to support extubation within a children's palliative care framework.

Enterobacter cloacae: an "ICU bug" causing community acquired necrotizing meningo-encephalitis.

Enterobacter cloacae is a gram negative bacillus that is ubiquitous as a contaminant and a pathogen in adult, paediatric, and neonatal ICUs. Its transmission is almost exclusively nosocomial with community acquired infection reported rarely. We report a case of community acquired, rapidly progressive E. cloacae meningo-encephalitis in a neonate. A three-week-old term infant presented from home, having been discharged from hospital within two days of delivery. She rapidly progressed to multi-organ dysfunction. Initial CT of her brain showed evidence of severe hypoxic changes and herniation of the frontal lobes through the anterior fontanelle. Care was withdrawn 72 hours after admission. Post mortem examination confirmed E.cloacae meningo-encephalitis as a cause of her death. The baby had not been in a critical care environment at any time before admission, making it highly likely to have been a community acquired infection. Transmission of the organism may have been vertical as maternal transmission with intestinal colonization of neonates with E. cloacae has previously been reported. This case confirms that infection with E. cloacae should be included in the differential diagnosis of any severely ill neonate presenting from the community, and antimicrobial therapy should be optimized accordingly.

The ABCs of recording paediatric cardiac arrests.

OBJECTIVE: To examine the quality and comprehensiveness of documentation in Paediatric 'cardiac arrests'. DESIGN: Retrospective chart review. SETTING: Tertiary care hospital wards, Paediatric Intensive Care and Accident and Emergency department. SUBJECTS: 41 children experiencing acute life-threatening events in hospital. RESULTS: Overall documentation of details related to time, place and personnel was highly variable but generally present in over half of the cases reviewed. Data relating to specific drug-related and interventional therapies was insufficient, as was documentation of time intervals and consequent therapeutic decisions. CONCLUSIONS: Documentation of critical resuscitation episodes in children is below recognised standards and this has potential quality of care and medicolegal implications. Current teaching needs to emphasise this essential aspect of clinical care from the earliest level of training.